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Report on Training of Health Facility Level Health workers Of

Sankhuwasabha District in Community-Based NNeeww BBoorrnn CCaarree

Program (CCBB--NNCCPP))

Sankhuwasabha 2011

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Contents page

1. Abbreviations---------------------------------------------------------------------3

2. Project Summary-----------------------------------------------------------------------4

3. Introduction ----------------------------------------------------------------------------5

4. Neonatal health status in Nepal------------------------------------------------5

5. CB-NCP Program in Nepal-----------------------------------------------------6

6. Report on CB-NCP training, Sankhuwasabha --------------------------------

• CB-NCP training, Sankhuwasabha ------------------------ 8

• Goals and Objectives-----------------------------------------9

• Training methodology---------------------------------------10

• Training Activities-------------------------------------------11

• Manpower-----------------------------------------------------12

• Major contents of the training------------------------------12

• Training Sessions--------------------------------------------13

7. Total Number of staff trained in CB-NCP, Sankhuwasabha ------------

8. Feedback from the participants----------------------------------------------17

9. Session Evaluation------------------------------------------------------------18

10. Recommendations-------------------------------------------------------------18

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Abbreviations

AHW ANM CB NCP CHD DHO DTLA DTOT FCHV HA

HETO HF HMG HP HW MASS MCHW MDG MO MOH NFHP OPD PHC PHN PHO SAHW SANM SHP SMO SN UNICEF VCI VHW WHO

Auxiliary Health Worker Auxiliary Nurse Midwifery Community Based New born care Program Child Health Division District Health Office/ Officer District Tuberculosis Leprosy Assistant District Training Of Trainers Female Community Health Volunteer Health Assistant Health Education Training Officer

Health Facility His Majesty's Government Health Post Health Worker

Management and Support Service Maternal Child Health Worker Millennium Developmental Goal Medical Officer Ministry of Health Nepal Family Health Programme Out Patient's Department Primary Health Center Public Health Nurse Public Health Officer Senior Auxiliary Health Worker

Senior Auxiliary Nurse Midwifery Sub Health Post

Senior Medical Officer Staff Nurse

United Nations International Children’s Emergency Fund Vector Control Inspector Village Health Worker

World Health Organization

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Project Summary

Strategic Objectives

•••• To train health workers working in Sankhuwasabha District in the skills of CB-NCP. •••• To improve the skills and knowledge of health workers of Sankhuwasabha district in

the management of neonates as per CB-NCP Protocols. •••• To conduct regular supervision and monitoring of CB-NCP implementation in the

district. •••• To reduce neonatal mortality in Sankhuwasabha District from the current neonatal

mortality rate of 33 per thousand live births to the 2015 MDG of 17 per 1000 live births.

Title of Activity:

• Training of Health Facility Level Health Workers of Sankhuwasabha district in Community Based Newborn Care Program (CB-NCP).

Target Population for CB-NCP Training of Bharatpur District.

CB-NCP HF level training

Duration: 21 days started from 7th jestha 2068 to 30th jestha 2068

Training venue

The training activities of CB-NCP, health facility level for Sankhuwasabha district were carried out in training hall at DHO, Sankhuwasabha.

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Strategies of CB-NCP Program in Nepal

� Improving knowledge and skill of health workers through training. � Improving the health system through monitoring and follow up visits � Improving the family and community practices through proper counseling.

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Report on CB-NCP training, Sankhuwasabha

District profile

Sankhuwasabha is one of the Himalaya district in the eastern developmental region of Nepal. It lies in koshi zone with total area of 1343.6 square metres surrounded by tehrethum and taplejung district from the east; solukhumbu district from the west; china from the north, and dhankuta from the south. Khandbari is the district hedquarter. Indigenous ethnics yakkhas, rais, limbus, and other hill casts (e.g. chhetris, bahuns) and ethnic groups (e.g. newars, sherpas) live in this district.

There is a district hospital at khandbari. 2 PHC, 11 HP, 25 SHP in this district. There are 118 PHC-ORC and 206 EPI clinic. There are total no of 325 FHCV in this district.

overall health status of Sankhuwasabha district viewed through different health indicators is indeed quite poor. The major indicators which focus on the overall development in the region are neonatal mortality rate, infant mortality rate, under five mortality rate and maternal mortality rate, which are significantly high. In order to improve the health status of the district we need to focus on these parameters and implement a package which will address them collectively. Various programs run by the Nepal Government like the CB-IMCI, Vitamin A and National Immunization program have helped to improve the health status of children to a great degree. But the current mortality rates can only be reduced further by concentrating on the neonatal well-being. CB-NCP focuses mainly on training all the health staff of the district from the grass root level health workers to the health facility level health workers and the district supervisors, which is the best part of the package.

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CB-NCP training, Sankhuwasabha

Ministry of Health, Child Health Division, UNICEF, DHO Sankhuwasabha & PHD group jointly conducted the training. CB-NCP has focused on promoting institutional delivery & reduction of neonatal mortality rate (0-28days). This program focuses on new born care, infection, LBW, prevention of hypothermia and birth asphyxia which are the major killers in neonates.

Almost all the health workers were trained in the year 2068.

The inauguration of the CB-NCP, Sankhuwasabha was carried out in training hall of DHO.Dr Krishna acharya was the chairparson and IMCI chief parsuram shrestha was chief guest who gave a brief introduction about the health status of new born in the country and focused on the need of this program..

CB-NCP is a seven days training package focusing on knowledge and skills update of the health worker, not merely disseminating the required information for the improvement of health status of neonate. It focuses on skill development by repeated demonstration classes by experienced facilitators and also clinical exposure in the pediatric unit,MCH clinic and labor room in Sankhuwasabha district Hospital.

Participant’s knowledge are evaluated before the training and in between by the facilitators by a set of questionnaire and demonstration of skills individually and repeated until they are perfect in each procedure. Every participant was provided with an equal opportunity to gain enough knowledge and develop skills through various ways like demonstration, micro teaching, observations in the real set up in hospital, where they could expand their knowledge and skills in practice.

On the closing day of the program all the participant were heartily thanked for their enthusiastic performance during the training period by the facilitators and encouraged to apply the skills learned in their work field effectively. The participants also expressed their commitment to implement CB-NCP and save newborn lives.

Goals and Objectives

Goal:

• To save newborn lives and improve the health status of newborn babies in Sankhuwasabha district.

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� General objectives:

• To achieve sustainable increase in the adoption of healthy newborn care practices and reduce prevailing harmful practices.

• To strengthen the quality of preventive and curative health service provided to newborn babies from the community level to the district level.

� Specific Objectives:

• To increase rate of delivery at health centers, by skilled birth attendants.

• To increase clean delivery practices and the use of delivery kits at home deliveries.

• To improve essential newborn care practices in the community.

• To increase the demand for, and the utilization of post-natal care services for mothers and newborns.

• To create awareness among mothers and other family members regarding newborn care, postnatal danger signs and to increase care seeking behavior from FCHV, Community Health Worker (MCHW/VHW) or appropriate health facility as required.

• To increase awareness and improve household practices for providing extra-care to LBW and VLBW newborns.

• To strengthens the quality of newborns services at community level through FCHV, Community Health Workers and Health Facilities and establishment of effective referral services at all levels.

� CB-NCP training has been delivered to DHO/PHC/HP/SHP Level HW =

Training methodology

1 Recruitment of Facilitators/Trainers and other field staffs

Info-AIDS recruited the necessary facilitators and staff for the program. The facilitators were highly experienced in conducting CB-IMCI/CB-NCP trainings in the past.

2. Training Materials

Modules:

The required set of modules and training materials were provided as per the National CB-NCP guidelines by CHD.

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Medicine and Other Commodities:

All the job aids and stationary were supplied to all the health workers and supervisors by DHO

The necessary modules required to conduct the demonstration in training sessions was provided by CHD

The necessary drugs required to conduct the training sessions was provided by DHO

3. Monitoring

Master trainer(MTOT) and Facilitators were responsible for the monitoring of the training activities and coordinate with the different level of health workers for the implementation of the program. They used standard checklists and also provided individual/group feedbacks and technical inputs as and when required. The final report is submitted by the Master trainer to PHD group.

Central monitoring team comprised of:

Regional monitoring team

This team made a field visit to the training site and evaluated the overall CB-NCP HF level training in Sankhuwasabha district.

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Training Activities The CB-NCP training of Sankhuwasabha district at health facility level was started on 7th jestha and was finished on 30th jestha . Each batch consisted of an average of 21 participants. The details of the number of batches and the persons involved are included at the end of the report.

Invitation to participants

The DHO was responsible for sending invitation letters to all the participants to ensure maximum possible participation.

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Health facility level clinical health worker training

This was a 7 day training to the clinical staffs of Sankhuwasabha district PHCs, HPs and SHP who are directly involved with the management of neonates.

Manpower The following strategy was adopted in utilization of skilled manpower at the health facility level CB-NCP training in Sankhuwasabha district. •••• Master trainer and tot holder local facilitators were involved to conduct the training

1st batch had two facilitator from Info-AIDS and remaining batches had 1 facilitator each from info-AIDS and the remaining facilitators were from DHO. The participant facilitator ratio was be maintained to 4: 1 .

Major contents of the training

The major contents covered in the seven day training sessions are as follows:

• Inter personnel communication. • Roles of FCHV, VHW/MCHW, HF level health worker and District Supervisors in

CB-NCP. • Hand washing.

• Immediate new born care. • Management of hypothermia. • Management of birth Asphyxia.

• Use of de-lee suction. • Use of bag and mask.

• Assessment, classification and management of sick neonates. • Assessment, classification and management of breastfeeding. • Assessment and management of low birth weight.

• Kangaroo Mother Care (KMC). • Counseling the Mother.

• Recording and reporting (HF/VHW/MCHW and FCHV levels). • Micro Teaching.

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Training Sessions

The Schedule of CB NCP training conducted in Bharatpur district for health facility level was as follows:

Batch Dates No. of Participants

1 7th jestha to 13th jestha 21

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Work Schedule

Day/Activities Classroom Session Clinical session

Day1 " X

Day2 " Clinical Session

Day3 " "

Day4 " "

Day5 " "

Day6 " X

Day7 " X

Note: Each day encompasses the time period from 8:00 am to 4:00 pm.

Participant expectations

At the start of the training, participants were asked to write down their expectations from this training, some of which have been included below:

• Know about infection in neonates and its management.

• To protect life of neonates and improve their health.

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• To know about neonatal care programme.

• Decrease the infant mortality rate.

• To conduct the CB-NCP training programme in community level.

• To manage low-birth weight neonates

• To know about the medicines used in the management of neonates.

• To know the individual roles of health workers in CB-NCP programme.

Class Room Session

Training modules approved by the CB-NCP National working group were provided to the participants for classroom session. Required modules were used for the demonstration sessions for effective skill development. A video related to the training content in Nepali and in the context of Nepal was used during the classroom session along with the wall charts demonstrations, role play, drill exercises, demonstration exercises, individual exercises and group exercises.

Around 60% o the training period was devoted for classroom session. The participant to facilitator ratio was maintained at 6:1

The classroom sessions for two batch was conduted in DHO training hall, Bharatpur. The clinical sessions were conducted in Bharatpur district hospital (post natal ward and labor room) and MCH clinic.

Clinical sessions

40% of the total training period was utilized for clinical session, which was equally distributed in indoor and out door sessions. During these sessions the participants practiced clinical skills learnt in the classroom sessions and was conducted in the post natal ward , MCH clinic and labor room . A clinical instructor and the facilitators assisted the participants in overall assessment of the sick children in the inpatient and outdoor sessions respectively. The incharge of the post natal ward ,labor room and MCH clinic helped to conduct indoor and outdoor session smoothly.

During the clinical sessions the participants were given selected neonates and asked to evaluate and manage as per CB-NCP training protocol. They were shown the important and rare clinical signs as and when the signs were identified by the facilitators.

Each participant was registered in a clinical monitoring and evaluation form for OPD. All the assessment and management done by the participants was noted in that check list. After the clinical session the participants were asked to note down the demonstrated clinical signs they had observed that day in OPD , which was discussed later in classroom.

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The total numbers of neonates evaluated in the clinical sessions are as follows:

Batch 1st 2nd

Total number of Neonates 18 18

Total number of Sick Neonates 0 1

PSBI 0 1

LBI 0 0

Feeding Problem/Low Weight 1 2

Hypothermia 1 1

Jaundice 0 1

Total Number of staff trained in CB-NCP, Bharatpur

1medical officer

2. Health Assistant (HA) 01 3. Senior AHW (SAHW) 4. Staff Nurse (SN) 00 5. Public Health Nurse (PHN) 00 7. Senior ANM (SANM) 8. AHW 9. ANM 10. District Supervisors Total:

Name of the facilitators involved to conduct two batch CBNCP HF Level in sankhuwasabha

1 Dr Dinesh chhetri 2 Dr Narendra bhattarai 3 Purusottam ghimire 4 Sita lama

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Feedback from the participants:

• Appropriate use of effective and efficient teaching techniques and methodologies for transfer of knowledge and skill.

• Intensive learning opportunity and exposure provided to the trainees by dividing four to five participants per group during demonstration exercises and clinical session.

• Use of video was very effective but a more comprehensive CB-NCP HF level training video should be developed.

• Use of learning modules for demonstration was very effective.

• Appropriate number of trainees and trainers.

• Full co-operation by the staffs at labor room, post natal ward and MCH clinic and less availability of sick neonates for the clinical sessions.

• Knowledge would be more complete if the side effects of drugs used in CB-NCP were included in the HF modules.

• Chart booklet should be revised.

• The responsibility given to FCHV is above their ability.

Session Evaluation

The participants were assessed at the start of the training program by a pre-test questionnaire. This provided a rough idea to the facilitators on which modules to focus on more intently during the training. At the end of the program, a post test was conducted to assess the knowledge acquired by the participants. Every session was evaluated by question answer sessions and group discussions.

Overall training program was evaluated at the end of the training through mood chart and participants views. The response received showed that all the participants were satisfied with the overall training package. Participants expressed their views that the training was fruitful, methods and materials used in training was interesting and effective and the facilitators were very good, confident and cooperative in delivering sessions. The basic evaluation components that were used in the training sessions are listed below.

• Pre-test questionnaire • Post-test questionnaire

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• Individual feedback session • Group discussion

• Participant views • Mood charts

• Summary and agenda sessions • Clinical sessions checklists

• Demonstration exercises

Recommendations:

♦♦♦♦ The training program should be held in a place where cases available for clinical practice are sufficient for effective acquisition of clinical knowledge and skills.

♦♦♦♦ Duplication of cases occurs in CB-NCP 6 where the same case may be followed up independently by the HF and FCHV on the first, third and seventh day.

♦♦♦♦ Recording forms for deliveries conducted by MCHW should be introduced. .

♦♦♦♦ It will be effective if participants were provided with module for FCHV at the of micro teaching.

♦♦♦♦ Separate training for recording and reporting should be conducted.

♦♦♦♦ Regular supervision and refresher training should be conducted. ♦♦♦♦ Flip chart for FCHV should be of large size.

♦♦♦♦ CB-NCP and CB-IMCI should be merged.

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